Mental State Examination

Background

MSE is a systematic appraisal of the
appearance, behaviour, mental functioning and overall demeanor of a
person. In some ways it reflects a "snapshot" of a person's
psychological functioning at a given point in time.

A MSE is an important component of the
assessment of a patient.

Most of us intuitively perform many parts of
a MSE every time we interact with or observe others.

Observations of person's mental state are
important in determining a person's capacity to function, and
whether psychiatric follow-up is required.

Judgements about mental state should always
consider the developmental level of the person and
age-appropriateness of the noted behaviour(s).

If there is any indication of current
suicidal or homicidal ideation the person must be referred for risk
assessment by a qualified mental health clinician.

Assessment

A typical MSE includes consideration of the
following domains:

Appearance

A person's appearance can provide useful clues
into their quality of self-care, lifestyle and daily living
skills.

distinctive features

clothing

grooming

hygiene

Behaviour

As well as noting what a person is actually
doing during the examination, attention should also be paid to
behaviours typically described as non-verbal
communication. These can reveal much about a person's
emotional state and attitude.

facial expression

body language and
gestures

posture

eye contact

response to the
assessment itself

rapport and social
engagement

level of arousal (e.g.
calm, agitated)

anxious or aggressive
behaviour

psychomotor activity and
movement (e.g. hyperactivity, hypoactivity)

unusual features (e.g.
tremors, or slowed, repetitive, or involuntary movements)

Mood and affect

It can be useful to conceptualise the
relationship between emotional affect and mood as being similar to
that between the weather (affect) and the season (mood).
Affect refers to immediate expressions of emotion, while mood
refers to emotional experience over a more prolonged period of
time.

Affect:

range (e.g. restricted,
blunted, flat, expansive)

appropriateness (e.g.
appropriate, inappropriate, incongruous)

stability (e.g. stable,
labile)

Mood:

happiness (eg, ecstatic, elevated, lowered, depressed)

irritability (e.g. explosive, irritable, calm)

stability

Speech

Speech can be a particularly revealing feature
of a person's presentation and should be described behaviourally as
well as considering its content (see also section on
Thoughts). Unusual speech is sometimes associated with mood
and anxiety problems, schizophrenia, and organic pathology.

speech rate (e.g. rapid, pressured, reduced
tempo)

volume (e.g. loud,
normal, soft)

tonality (e.g.
monotonous, tremulous)

quantity (e.g. minimal,
voluble)

ease of
conversation

Cognition

This refers to a person's current capacity to
process information and is important because it is often sensitive
(though in young people usually secondary) to mental health
problems.

level of consciousness (e.g. alert, drowsy,
intoxicated, stuporose)

orientation to reality (often expressed in regard to
time/place/person - e.g. awareness of the time/day/date, where they
are, ability to provide personal details)

memory
functioning (including immediate or short-term memory, and memory
for recent and remote information or events)

literacy and arithmetic skills

visuospatial processing (e.g. copying a diagram,
drawing a bicycle)

attention and concentration (e.g. observations about
level of distractibility, or performance on a mentally effortful
task - e.g. counting backwards by 7's from 100)

general knowledge

language (e.g. naming objects, following
instructions)

ability to deal with
abstract concepts (e.g. describing conceptual similarity between
two things).

Thoughts

A person's thinking is generally evaluated
according to their thought content or nature, and
thought form or process.

Content:

delusions (rigidly held false beliefs not
consistent with the person's background)

overvalued ideas (unreasonable belief, e.g. a
person with anorexia believing they are overweight)

preoccupations

depressive thoughts

self-harm, suicidal, aggressive or homicidal
ideation

obsessions (preoccupying and repetitive
thoughts about a feared or catastrophic outcome, often indicated by
associated compulsive behaviour)

Process:

Thought process refers to the formation and
coherence of thoughts and is inferred very much through the
person's speech and expression of ideas.

highly irrelevant comments (loose associations or
derailment)

frequent changes of topic (flight of ideas or tangential
thinking)

excessive vagueness (circumstantial thinking)

nonsense words (or word salad)

pressured or halted speech (thought racing or blocking)

Perception

Screening for perceptual disturbance is
critical for detecting serious mental health problems like
psychosis (this is relatively rare in young people, though peak
onset is between 19 and 22 years), cases of severe anxiety, and
mood disorders. It is also important in trauma or substance
abuse. Perceptual disturbances are
typically marked and may be disturbing or frightening.

Dissociative
symptoms:

derealisation (feeling
that the world or one's surroundings are not real)

depersonalisation (feeling
detached from oneself)

Illusions:

the person perceives things as different to
usual, but accepts that they are not real, or that

things are perceived differently by
others

Hallucinations:

probably the most widely known form of
perceptual disturbance

hallucinations are indistinguishable by the
sufferer from reality

can affect all sensory modalities, although
auditory hallucinations are the most common

in children it is common to experience self-talk or commentary
as an internal "voice"

command hallucinations (voices telling the person to do
something) should be investigated

important to note the degree of fear and/or distress associated
with the hallucinations

Insight & Judgement

Insight and judgement is particularly
important in triaging psychiatric presentations and making
decisions about safety.

Insight:

acknowledgement of a possible mental health
problem

understanding of possible treatment options
and ability to comply with these

Judgement:

can be evaluated by exploring recent decision-making or by
posing a practical dilemma (e.g. what should you do if you see
smoke coming out of a house?)

Management

Unusual or incongruous features noted in a MSE
may indicate the need for the involvement of Mental Health
services, particularly where there is disturbed perception and/or
thought processes. Consideration of the above domains will
help in this determination, and will facilitate the process of
seeking a secondary consultation or making a mental health
referral. Please note again that if there is any indication
of current suicidal or homicidal ideation the person must be
referred for risk assessment by a qualified mental health
clinician.